Definitions

CPT® and HCPCS code modifiers mentioned in this chapter:

Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure

Payment is made at 100% of the fee schedule level or billed charge, whichever is less.

–47

Anesthesia by surgeon

–99

Multiple modifiers

This modifier should only be used when two or more modifiers affect payment. Payment is based on the policy associated with each individual modifier that describes the services performed. For billing purposes, only modifier –99 should go in the modifier column, with the individual descriptive modifiers that affect payment listed elsewhere on the billing form.

–AA

Anesthesia services performed personally by anesthesiologist

–P1

A normal healthy patient

–P2

A patient with mild systemic disease

–P3

A patient with severe systemic disease

–P4

A patient with severe systemic disease that is a constant threat to life

–P5

A moribund patient who is not expected to survive without the operation

–P6

A declared brain-dead patient whose organs are being removed for donor purposes

Requirements for billing

Anesthesia add-on codes

Anesthesia add-on codes must be billed with a primary anesthesia code. There are three anesthesia add-on CPT® codes: 01953, 01968, and 01969:

Add-on code 01953 should be billed with primary code 01952,

Add-on codes 01968 and 01969 should be billed with primary code 01967,

Add-on codes 01968 and 01969 should be billed in the same manner as other anesthesia codes paid with base and time units.

Note: Providers should report the total time for the add-on procedure (in minutes) in the “Units” column (Field 24G) of the CMS-1500 form.

Anesthesia for burn excisions or debridement (CPT® add-on code 01953)

The anesthesia add-on code for burn excision or debridement must be billed as follows:

If the total body surface area is…

Then the primary code to bill is:

And the units to bill of add-on code 01953 is:

Less than 4 percent

01951

None

5 - 9 percent

01952

None

Up to 18 percent

01952

1

Up to 27 percent

01952

2

Up to 36 percent

01952

3

Up to 45 percent

01952

4

Up to 54 percent

01952

5

Up to 63 percent

01952

6

Up to 72 percent

01952

7

Up to 81 percent

01952

8

Up to 90 percent

01952

9

Up to 99 percent

01952

10

Anesthesia base units

List only the time in minutes on your bill. Don’t include the base units (L&I’s payment system automatically adds the base units).

Note: Most of L&I’s anesthesia base units are the same as the units adopted by CMS. L&I differs from the CMS base units for some procedure codes based on input from the ATAG (see more about the ATAG in “Additional information: How anesthesia payment policies are established,” below).

The maximum payment for anesthesia services paid with base and time units is calculated using the:

Base value for the procedure, and

Time the anesthesia service is administered, and

L&I anesthesia conversion factor.

To determine the maximum payment for physician services:

Multiply the base units listed in the fee schedule by 15, then

Add the value from step 1 to the total number of whole minutes, then

Multiply the result from step 2 by $3.22.Example: CPT® code 01382 (anesthesia for knee arthroscopy) has three anesthesia base units. If the anesthesia service takes 60 minutes, the maximum physician payment would be calculated as follows:

3 base units x 15 = 45 base units,

45 base units + 60 time units (minutes) = 105 base and time units,

Maximum payment for physicians = 105 x $3.22 = $338.10.

Payment policy: RBRVS payment method for anesthesia

Which services are paid using the RBRVS method

Some services commonly performed by anesthesiologists and CRNAs are paid using the RBRVS payment method, including:

Anesthesia evaluation and management services, and

Most pain management services, and

Other selected services.

Injection code treatment limits

If the injection type is…

Then the treatment limit is:

Epidural and caudal injections of substances other than anesthetic or contrast solution

Maximum of 6 injections per acute episode are allowed.

Facet injections

Maximum of 4 injection procedures per patient are allowed.

Intramuscular and trigger point injections of steroids and other nonscheduled medications and trigger point dry needling (see more explanation below this table)

Maximum of 6 injections per patient are allowed.

Dry needling is considered a variant of trigger point injections with medications. It is a technique where needles are inserted (no medications are injected) directly into trigger point locations, as opposed to the distant points or meridians used in acupuncture.

Links: Details regarding treatment guidelines and limits for the injections listed above can also be found in WAC 296-20-03001 (for example, dry needling follows the same rules as trigger point injections).

Requirements for medical direction of anesthesia

Participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence, and

Make sure any procedures in the anesthesia plan that he/she doesn’t perform are performed by a qualified individual as defined in program operating instructions, and

Monitor the course of anesthesia administration at frequent intervals, and

Remain physically present and available for immediate diagnosis and treatment of emergencies, and

Provide indicated postanesthesia care.

In addition, physicians directing anesthesia:

May direct no more than 4 anesthesia services concurrently, and

May not perform any other services while directing the single or concurrent services.

The physician may attend to medical emergencies and perform other limited services as allowed by Medicare instructions and still be deemed to have medically directed anesthesia procedures.

Documentation requirements for team care

Documentation requirements for team care

The physician must document in the patient’s medical record that the medical direction requirements were met. The physician doesn’t submit documentation to the insurer, but must make it available upon request.

Requirements for billing

When billing for team care situations:

Anesthesiologists and CRNAs must report their services on separate CMS-1500 forms using their own provider account numbers,

Anesthesiologists must use the appropriate modifier for medical direction or supervision (–QK or –QY),

CRNAs should use modifier –QX.

How to calculate payment for team care

To determine the maximum payment for team care services:

Calculate the maximum payment for solo physician services (see the “How to calculate anesthesia payment paid with base and time units” in the payment policy for “Base and time units payment method for anesthesia” section of this chapter),

The maximum payment to the physician is 50% of the maximum payment for solo physician services,

The maximum payment to the CRNA is 45% of the maximum payment for solo physician services (90% of the other 50% share).